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1.  Experiencing a first food allergic reaction: a survey of parent and caregiver perspectives 
Background
Insufficient knowledge of food allergy and anaphylaxis has been identified by caregivers as an important barrier to coping, and a potential cause of fear and anxiety, particularly for those with children newly diagnosed with food allergy.
The purpose of the study was to better understand the experiences of caregivers of children with a first allergic reaction to food, and to identify any deficiencies in the information received at diagnosis.
Methods
A mixed-methods study consisting of an online survey administered to the Anaphylaxis Canada online registry (a patient support group database of approximately 10,000 members), and a follow-up qualitative interview with a subset of survey participants. Analysis consisted of frequency analysis (quantitative and qualitative data) and descriptive statistics to calculate proportions and means with standard deviations. Qualitative analyses were guided by the constant comparative method of grounded theory methodology.
Results
Of 293 survey respondents, 208 were eligible to complete the survey (first allergic reaction to food within 12 months of the study), and 184 respondents consented. Identified gaps included education about food allergy, anaphylaxis management, for example, how to use epinephrine auto- injectors, and coping strategies for fear and anxiety. The qualitative follow-up study supported these findings, yielding 3 major themes: 1) lack of provision of information following the episode on the recognition and management of food allergy related allergic reactions, 2) prolonged wait times for an allergist, and 3) significant family anxiety.
Conclusions
The online survey highlighted multiple deficiencies at diagnosis, findings which were supported by the follow up qualitative study. Results will inform the development of educational strategies for patients newly diagnosed with food allergy.
doi:10.1186/1710-1492-9-18
PMCID: PMC3671211  PMID: 23718700
Anaphylaxis; Food allergy; Qualitative methods
2.  Comparing School Environments With and Without Legislation for the Prevention and Management of Anaphylaxis 
Allergy  2011;67(1):131-137.
Background
School personnel in contact with students with life-threatening allergies often lack necessary supports, creating a potentially dangerous situation. Sabrina’s Law, the first legislation in the world designed to protect such children, requires all Ontario public schools to have a plan to protect children at risk. Though it has captured international attention, the differences a legislative approach makes have not been identified. Our study compared the approaches to anaphylaxis prevention and management in schools with and without legislation.
Methods
Legislated (Ontario) and non-legislated (Alberta, British Columbia, Newfoundland and Labrador, and Quebec) environments were compared. School board anaphylaxis policies were assessed for consistency with Canadian anaphylaxis guidelines. Parents of at-risk children and school personnel were surveyed to determine their perspectives on school practices. School personnel’s EpiPen technique was assessed.
Results
Consistency of school board policies with anaphylaxis guidelines was significantly better in a legislated environment (p=0.009). Parents in a legislated environment reported more comprehensive anaphylaxis emergency forms (p< 0.001), while school personnel in non-legislated environments reported more comprehensive forms (p=0.004). Despite school personnel in both environments receiving EpiPen training (>80%), suboptimal technique was commonly observed. However, school personnel in the legislated environment had better technique (p < 0.001).
Conclusion
Our results suggest that school boards in legislated environments have made greater efforts to support students at-risk for anaphylaxis compared to non-legislated environments. However, significant gaps exist in both environments, especially with respect to EpiPen administration, content and distribution of anaphylaxis emergency forms, and awareness of school procedures by school personnel and parents.
doi:10.1111/j.1398-9995.2011.02721.x
PMCID: PMC3237918  PMID: 21951319
Anaphylaxis; life-threatening allergies; policy; Sabrina’s Law; school
4.  Local and systemic immunological parameters associated with remission of asthma symptoms in children 
The immunological and clinical parameters that are associated with asthma remission are poorly understood. The cytokine and local mediator changes associated with the resolution of asthma symptoms were examined in three groups of subjects 12–18 years of age (n = 15 in each group): (a) continuing asthma group (CA) who had persistent symptoms since early childhood, (b) an age, sex and atopic status-matched group who had persistent symptoms in early childhood but in whom these had resolved (RA), and (c) a non-atopic, non-asthmatic control group. Clinical parameters, sputum cell counts, peripheral blood mononuclear cell (PBMC) cytokine production and activation marker expression were determined. All of the CA had methacholine airway hyperresponsiveness compared with only half of the RA subjects. The CA showed elevated numbers of eosinophils and increased ECP and IL-5 in sputum, which were not observed in the RA. PBMC cytokine studies revealed increased production of the type 1 cytokines IL-12, IFN-γ and TNF-α in the CA group compared with the RA group, under a range of activation conditions, however, the production of IL-4 and IL-5 were unchanged. These findings suggest that decreased type 1 cytokine expression as well as decreased eosinophilic inflammation is associated with the resolution of asthma symptoms.
doi:10.1186/1710-1492-8-16
PMCID: PMC3599667  PMID: 23043798
Asthma in children; Eosinophils; IL-5; TNF-α; IL-12
5.  Management of anaphylaxis in schools: Evaluation of an epinephrine auto-injector (EpiPen®) use by school personnel and comparison of two approaches of soliciting participation 
Background
There has been no large study characterizing selection bias in allergy and evaluating school personnel’s ability to use an epinephrine auto-injector (EpiPen®). Our objective was to determine if the consent process introduces selection bias by comparing 2 methods of soliciting participation of school personnel in a study evaluating their ability to demonstrate the EpiPen®.
Methods
School personnel from randomly selected schools in Quebec were approached using a 1) partial or 2) full disclosure approach and were assessed on their ability to use the EpiPen® and identify anaphylaxis.
Results
343 school personnel participated. In the full disclosure group, the participation rate was lower: 21.9% (95%CI, 19.0%-25.2%) versus 40.7% (95%CI, 36.1%-45.3%), but more participants achieved a perfect score: 26.3% (95%CI, 19.6%-33.9%) versus 15.8% (95%CI, 10.8%-21.8%), and identified 3 signs of anaphylaxis: 71.8% (95%CI, 64.0%-78.7%) versus 55.6% (95%CI, 48.2%-62.9%).
Conclusions
Selection bias is suspected as school personnel who were fully informed of the purpose of the assessment were less likely to participate; those who participated among the fully informed were more likely to earn perfect scores and identify anaphylaxis. As the process of consent can influence participation and bias outcomes, researchers and Ethics Boards need to consider conditions under which studies can proceed without full consent. Despite training, school personnel perform poorly when asked to demonstrate the EpiPen®.
doi:10.1186/1710-1492-8-4
PMCID: PMC3391991  PMID: 22537343
Anaphylaxis; Epinephrine; Food allergy; School; Treatment; Selection bias; Consent bias; Volunteer bias
6.  The burden of allergic rhinitis (AR) in Canada: perspectives of physicians and patients 
Background
Allergic rhinitis (AR) is a common problem and we sought to examine the burden of disease and its management in Canada from the perspectives of patients and physicians.
Methods
Two parallel, Canadawide structured telephone interviews surveyed 1,001 AR patients and 160 physicians in July 2006.
Results
44% of patients had experienced nasal symptoms unrelated to a cold and 20% had a physician diagnosis of AR. At screening 27% reported asthma, 15% chronic or recurrent sinusitis and 5% nasal polyps. With attacks nasal congestion and runny nose were the most bothersome symptoms. Other problems experienced were fatigue (46%), poor concentration (32%), and reduced productivity (23%). Most (77%) had not seen a physician in the past year. Physicians estimated they prescribed intranasal cortico steroids (INCS) to most AR patients (77%) consistent with guidelines but only 19% of patients had used one in the last month. Only 48% of patients were very satisfied with their current INCS. 41% of AR patients reported discontinuing their INCS with the most common reason being a perceived lack of long-lasting symptom relief (44%). 52% of patients felt that their current INCS lost effectiveness over 24 h. The most common INCS side effects included dripping down the throat, bad taste, and dryness. Most AR patients reported lifestyle limitations despite treatment (66%). 61% of patients felt that their symptoms were only somewhat controlled or poorly/not controlled during their worst month in the past year.
Conclusions
AR symptoms are common and many patients experience inadequate control. Physicians report they commonly prescribe intranasal corticosteroids, but patient’s perceived loss of efficacy and side effects lead to their discontinuation. Persistent relief of allergic rhinitis symptoms remains a major unmet need. Better treatments and education are required.
doi:10.1186/1710-1492-8-7
PMCID: PMC3490734  PMID: 22656186
Rhinitis, Allergic; Anti-allergic agents; Administration, Intranasal; Quality of life
7.  490 Immunotherapy (IT) Training in Canada: Perspectives of Fellows-in-training on the First Immunotherapy Training Manual 
The World Allergy Organization Journal  2012;5(Suppl 2):S172-S173.
Background
Allergen immunotherapy (IT) is a key component of allergy practice, however fellows state that there is inadequate IT exposure during their training. In response, the Canadian Society of Allergy and Clinical Immunology (CSACI) unveiled the first ever IT Training Manual for fellows-in-training at the annual 2010 CSACI meeting. The manual was distributed during a faculty-led teaching session. This was a pilot investigation to determine the perspectives of fellows in training about the IT training manual.
Methods
Canadian fellows-in-training in Allergy and Clinical Immunology (list derived from CSACI) were contacted via email to complete a survey (using survey monkey), both quantitative (Likert scales) and qualitative, to assess their opinion on the faculty-led session on IT and the IT Training Manual.
Results
Sixty-nine Canadian fellows-in-training were invited to complete the survey and 16 (23%). Fifty-four percent of 13 respondents were in their first year of fellowship. Seven respondents (58% of 12 respondents) attended the 2010 CSACI fellow-in-training session and received the IT Training Manual. One respondent commented that it was “more information than we've had in all of our fellowship!” The same 7 respondents “somewhat liked” or “liked” the large group format, but felt that the experience could be improved in the future with the addition of cased-based learning in smaller groups. One respondent commented that “as in intro, it was good in a larger setting.” All 7 respondents felt that their understanding of IT was positively impacted by the faculty-led session. Eighty-six percent of 7 respondents indicated that the Training Manual “somewhat impacted” to “very much impacted” their understanding of IT. One commenter stated that “it is the basis of my knowledge thus far.” Most respondents (86%) preferred the current paper booklet format of the IT Training Manual.
Conclusions
The results of this pilot survey demonstrate that some fellows-in-training found the faculty-led session on IT and the IT Training Manual useful. Future studies will help to further elucidate the utility of these 2 educational interventions.
doi:10.1097/01.WOX.0000411605.50432.2f
PMCID: PMC3512639
8.  491 Immunotherapy (IT) Training in Canada: Current Experience of Fellows-in-training 
Background
Allergen immunotherapy (IT) is a key component of allergy practice of allergy. Canadian fellows-in-training have expressed concern that they receive inadequate exposure to IT in their training programs.
Methods
Canadian fellows-in-training in Allergy and Clinical Immunology, identified through the Canadian Society of Allergy and Clinical Immunology (CSACI), were contacted via email to complete a pilot survey (using survey monkey) to assess their exposure to, experience with, and comfort level in using IT.
Results
Sixty-nine Canadian fellows-in-training were invited to complete the survey and 16 (23%) completed at least part of the survey. Fifty-four percent of 13 respondents were in their first year of fellowship. Fifty percent of 12 respondents were internal medicine trained. Eighty-three percent of 12 respondents acknowledged exposure to IT during their training. Eighty percent of 10 respondents had previously written a prescription for IT; 71% and 43% of 7 respondents had written 1 to 5 prescriptions for aeroallergen and stinging venom IT, respectively. Only 50% of 12 respondents felt comfortable prescribing IT. The most common reason cited was lack of experience; however, one respondent wrote that he/she would feel uncomfortable prescribing IT without using the standardized hospital IT form. Sixty-seven percent of 12 respondents had previously administered IT to a patient. Sixteen percent of 12 respondents felt uncomfortable administering IT due to lack of experience. Fifty percent of 12 respondents had treated a patient having an allergic reaction to IT and 100% of these same respondents felt "somewhat comfortable" to "very comfortable" in responding to an allergic reaction to IT. Seventy-five percent of 12 respondents agreed that a formal clinical rotation in IT would be helpful.
Conclusions
The results of this pilot survey demonstrate that Canadian fellows-in-training in Allergy and Clinical Immunology are not receiving adequate exposure and training in IT. Future studies will help to explore this subject in more detail.
doi:10.1097/01.WOX.0000411606.27561.e2
PMCID: PMC3512924
10.  Food allergy 
Food allergy is defined as an adverse immunologic response to a dietary protein. Food-related reactions are associated with a broad array of signs and symptoms that may involve many bodily systems including the skin, gastrointestinal and respiratory tracts, and cardiovascular system. Food allergy is a leading cause of anaphylaxis and, therefore, referral to an allergist for appropriate and timely diagnosis and treatment is imperative. Diagnosis involves a careful history and diagnostic tests, such as skin prick testing, serum-specific immunoglobulin E (IgE) testing and, if indicated, oral food challenges. Once the diagnosis of food allergy is confirmed, strict elimination of the offending food allergen from the diet is generally necessary. For patients with significant systemic symptoms, the treatment of choice is epinephrine administered by intramuscular injection into the lateral thigh. Although most children “outgrow” allergies to milk, egg, soy and wheat, allergies to peanut, tree nuts, fish and shellfish are often lifelong. This article provides an overview of the epidemiology, pathophysiology, diagnosis, management and prognosis of patients with food allergy.
doi:10.1186/1710-1492-7-S1-S7
PMCID: PMC3245440  PMID: 22166142
11.  Food allergy management from the perspective of patients or caregivers, and allergists: a qualitative study 
Background
Research has shown that the long term management of food allergy is suboptimal. Our study aims to provide direction for improvement, by evaluating food allergy management from the perspective of, food allergic patients or their caregivers, and allergists in selected outpatient settings in Ontario.
Methods
This two-part study included an anonymous questionnaire completed by patients or their caregivers in allergy clinics, and a qualitative interview with allergists. In Part A, food allergic patients or their caregivers were surveyed about information they received on food allergy, their level of confidence with self-management, and their learning needs. In Part B, allergists were interviewed about teaching priorities and the challenges and strategies that currently exist in food allergy management. The questionnaire was developed and piloted at the Hamilton Health Sciences Corporation-McMaster University Medical Center Site. Using convenience sampling, participants were recruited from 6 allergy clinics in 5 Ontario cities. Patients of any age with food allergy who were evaluated by an allergist were considered for inclusion. Quantitative data was analyzed using descriptive statistics and frequency analysis. Audio recorded interviews with allergists were transcribed verbatim and analyzed using content analysis of grounded theory methodology.
Results
Ninety-two food allergic families in the care of 6 allergists in Toronto, Hamilton, London, Kitchener, and Kingston participated in the study. Key areas requiring improvement in food allergy management were identified: 33% of families were not shown how to use an epinephrine auto-injector with a trainer, only 57% were asked to demonstrate an auto-injector, despite being on average at their 5th visit, and only about 30% felt very confident about when and how to give an auto-injector. Fifty percent of families did not receive sufficient information on medical identification and 21% did not receive information about support groups. Interviews with allergists revealed limitations in time and nursing resources.
Conclusions
Our study highlights the educational gaps and overall experiences of food allergic families in Ontario, and the challenges faced by the allergists managing them.
doi:10.1186/1710-1492-6-30
PMCID: PMC3002337  PMID: 21118534
15.  2010 International consensus algorithm for the diagnosis, therapy and management of hereditary angioedema 
Background
We published the Canadian 2003 International Consensus Algorithm for the Diagnosis, Therapy, and Management of Hereditary Angioedema (HAE; C1 inhibitor [C1-INH] deficiency) and updated this as Hereditary angioedema: a current state-of-the-art review: Canadian Hungarian 2007 International Consensus Algorithm for the Diagnosis, Therapy, and Management of Hereditary Angioedema.
Objective
To update the International Consensus Algorithm for the Diagnosis, Therapy and Management of Hereditary Angioedema (circa 2010).
Methods
The Canadian Hereditary Angioedema Network (CHAEN)/Réseau Canadien d'angioédème héréditaire (RCAH) http://www.haecanada.com and cosponsors University of Calgary and the Canadian Society of Allergy and Clinical Immunology (with an unrestricted educational grant from CSL Behring) held our third Conference May 15th to 16th, 2010 in Toronto Canada to update our consensus approach. The Consensus document was reviewed at the meeting and then circulated for review.
Results
This manuscript is the 2010 International Consensus Algorithm for the Diagnosis, Therapy and Management of Hereditary Angioedema that resulted from that conference.
Conclusions
Consensus approach is only an interim guide to a complex disorder such as HAE and should be replaced as soon as possible with large phase III and IV clinical trials, meta analyses, and using data base registry validation of approaches including quality of life and cost benefit analyses, followed by large head-to-head clinical trials and then evidence-based guidelines and standards for HAE disease management.
doi:10.1186/1710-1492-6-24
PMCID: PMC2921362  PMID: 20667127
16.  Hodgkin's lymphoma presenting with markedly elevated IgE: a case report 
Background
Markedly elevated IgE as a manifestation of a lymphoproliferative disorder has been only rarely reported.
Case Presentation
We present the case of a 22 year old female referred to the adult Allergy & Clinical Immunology clinic for an extremely elevated IgE level, eventually diagnosed with Hodgkin's lymphoma. She had no history of atopy, recurrent infections, eczema or periodontal disease; stool was negative for ova & parasites. Chest X-ray revealed large bilateral anterior mediastinal masses that demonstrated prominent uptake on gallium scan. Mediastinal lymph node biopsy was consistent with Hodgkin's lymphoma, nodular sclerosing subtype, grade I/II.
Conclusion
Although uncommon, markedly elevated IgE may be a manifestation of a malignant process, most notably both Hodgkin's and Non-Hodgkin's lymphomas. This diagnosis should be considered in evaluating an otherwise unexplained elevation of IgE.
doi:10.1186/1710-1492-5-12
PMCID: PMC2794847  PMID: 20016775

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